The future is already here — it’s just not very evenly distributed. – William Gibson

When discussing payment reform, no quote could be more true. Everyone in health care knows changes are coming, knows organizations that are testing and implementing new care and delivery models, but the distribution is tremendously uneven. And the benefits for jumping in, even into the shallow end of the pool, seem murky.

But, getting ready for value based payment takes time. And there are several reasons practices need to pay attention to this issue in 2016.

In a previous post on value-based payment on the Kentucky REC’s blog, we focused on surprises ahead for practices. Among the surprises are changes coming due to the Medicare Physician Feedback/Value-Based Payment Modifier Program and the Medicare Access and CHIP Reauthorization Act (MACRA). The Value-based Modifier program began in 2015 with practices having 100 or more providers. Beginning in 2016, the VM program will affect groups of 10 providers or more, and then it will apply to all Medicare providers in 2017. Even more significant changes under the MACRA legislation are anticipated to begin in 2017.

Few providers are really knowledgeable about these programs. An even bigger problem is that by the time a provider gets a penalty and wants to do something about it, it will take the practice two years or more to fix the problem. This means not just one penalty but likely two or three years’ worth.

The Kentucky REC will be rolling out a new service line this year to help practices get ready for the changes ahead and navigate the complex alphabet soup of value-based payment. Our team has identified four immediate strategies necessary for success with value-based payments and new accountable care models. There are many more steps on the journey to value-based care but these are four pivotal actions for practices to take in 2016.

1. Form a team and task it to develop an action plan for getting the practice ready for value-based payment.

Since transformation requires a culture change, it is imperative that a team is formed with support from leadership to ensure that change is sustained over time. Without engaged leaders to provide direction, motivation, and resources, practices struggle to make and sustain the changes required for transformation. A key role of leaders during the transition to VBP is to identify and allocate resources such as time, money, staffing, and so on to help staff implement or sustain changes. The team should include, if possible, a physician champion, nurse lead, as well as financial and administrative staff.

One of the team’s first tasks will be to select a strong, organized leader to serve as project manager or coordinator for the team’s efforts. Leaders also need to make sure that this chosen staff person has protected time to work on VBP process.

2. Get your data in order. Use your EHR for all its worth.

The Physician Quality Reporting System (PQRS) used to be a voluntary program for Medicare providers, but no more. Practices that did not report data for PQRS in 2015 will be subject to a 2% penalty in 2017. Going forward, PQRS reporting will play a big role in Value Modifier penalties or bonuses for practices. Practices need to look at their PQRS measures and develop a plan of attack for improving performance on those measures. Using your EHR for all its worth is key for reporting on quality, identifying opportunities for improvement and monitoring whether interventions are making a difference in performance on specific measures.

Practices also need to begin locating sources of utilization data. Many practices are unaware that they can get Quality and Resource Use Reports (QRUR) from CMS that contain valuable information about how their practice performs in comparison to benchmarks based on Medicare claims data. Click here for an example of what a QRUR looks like. Other payers may offer similar reports on a quarterly, semi-annual or annual basis. These reports are important for practices to get a sense of their performance vis-à-vis their peers.

3. Empanel your patients.

Empanelment is the process whereby a primary care provider or a specialist and a practice team assume responsibility for a group of patients. This ensures that the practice team “owns” the health and well-being of a population of patients. Having responsibility for a specific panel of patients means care teams can track and monitor progress against goals on that population of patients. Empanelment involves looking at a list of patients and using an accepted methodology to match patients to a provider. The REC has resources and methods to help practice teams with empanelment.

Empanelment is important for a number of reasons. It will help your practice be ahead of the game in reviewing your list of patients with CMS’ or other payers’ lists of attributed beneficiaries/members. In addition, once a practice has empaneled its patient population, panel data is available to proactively contact, track and educate patients by: disease status; risk status; self-management status; and community/family need.

4. Develop population management and care management processes.

Once patients are empaneled, care teams within a practice can then undertake a variety of activities aimed at improving the health outcomes and cost profile for that population of patients. Because typically 5 percent of patients are responsible for 50 percent of costs, identifying patients most at risk for complications or unnecessary utilization (such as avoidable ED visits and hospital readmissions) can help with improving care and lowering costs. Appropriate management of chronic conditions such as diabetes, coronary artery disease, and hypertension is critical to getting those unnecessary costs under control.

Frequently, high performing care teams will use risk stratification to prioritize their population health improvement efforts and focus on patients with the greatest potential for preventable, high cost complications. Risk stratification uses various factors to group patients into categories of need. These categories include:

• number of past utilizations
• chronic disease state
• poor health status

Practices then use a variety of interventions to proactively manage their high-risk patients. These behaviors help ensure patients are receiving the right care at the right time. Some of them are:

• tracking patients in a registry to identify gaps in care
• patient outreach by a nurse MA or care manager
• pre-visit planning
• patient education and self-management

The Kentucky REC is here to help. Stay tuned for our upcoming March Webinars on MACRA and Value-Based Purchasing. If your practice is interested in learning more or would like some help, give us a call at 859.323.3090.